Community Benefit Activity Report
|Community Benefit Tracking Report |
|Submitting Department:_________________ Date:__________ |
Instructions: This form is to be used in reporting programs or services that your department provides for the benefit of the community.
• The program or service must address a community need.
• The program’s purpose is to benefit the community rather than the organization.
|What was the name of the program? |
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|Briefly describe: |
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|How did this program benefit the community? |
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|What population in this community did the program target (medically underserved, low income, minority? |
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|Provide the dates and locations of activities: |
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|How many persons were served? |
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|Attach a detail of expenses related to this program (see attached form) |
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|Were there any grants, contributions or other funds donated for this program? If so, list below. |
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|Were any community partners involved in program? If so, list: |
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|Other Comments: |
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|Contact person name, phone number and e-mail address: |
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|Community Benefit Activity Costs |
|(file one report for each activity occurrence) |
|Submit report to Accounting Office |
|Project |Project Coordinator |
|# Persons served |# Handouts |Code | |
|Activity Date: Activity Location: |
|NOTE: The dollar value of time spent by salaried employees can be included if the employee is participating during “paid work time” AND if participation is clearly|
|part of the individual’s job responsibilities. |
|Complete only non-shaded areas below. |
|Personnel: | | | | | |
| Name |Dept. |Hours |Direct cost |Indirect costs | |
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|Materials: attach support | | | | |
|Description | | |Direct cost |Indirect costs | |
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|Other expenses: attach support | | | |
|Description | | |Direct cost |Indirect costs | |
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| | | |Direct |Indirect |Total |
| |Total Costs | | | | |
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